14 November 2012

Medical Malpractice and Treating Tragedies as Political Footballs

The horrific news last night that a 31-year-old dentist, SavitaHalappanavar, died from septicaemia a fortnight ago following a miscarriage in Galway University Hospital looks almost as perplexing as it is tragic. I'm glad that two investigations are currently taking place into what exactly happened, because the whole thing mystifies and appalls me.

Seemingly Savita presented at hospital seventeen weeks pregnant and in extreme pain, and was told she was miscarrying; the following day she asked for the pregnancy to be terminated, but was denied one on the basis that the child was still alive, with somebody saying 'this is a Catholic country'; she remained in pain for two-and-a-half further days until the foetal heartbeat stopped.

The Irish Times goes on to say that the third day Savita was in hospital she asked if labour could be induced to end the pregnancy, but the consultant refused, again apparently saying it was the law and 'this is a Catholic country'. Savita remained in agony all that night and into a fourth day, but the hospital refused to end this. Eventually the foetal heartbeat stopped, and Savita was taken to ward.

Two days later she died.

Obviously this is horrible, sickening, and tragic.

I hope those investigations get to the bottom of what happened. I'd hope too, that appropriate action be taken if anyone claimed that the hospital couldn't help Savita as it would be against the law for it to do so, especially on the spurious grounds that, as was supposedly said, 'this is a Catholic country'. And if the hospital's negligence veered into the realms of the criminal, then I really hope there are suitable consequences.

The thing is, assuming that the reporting is accurate, and given the Irish Times' recent record on life issues, it may not be, this doesn't make sense. As far as I can see, Galway University Hospital would have been fully within its legal rights to have induced a preterm delivery -- or foetal evacuation -- in an attempt to save both mother and child. Indeed, not merely would it have been within its rights to do so, doing so would have been normal medical practice.

This is exactly the sort of thing that Dr Berry Kiely talked about back on what was an uncommonly good Vincent Browne show back in the Spring -- you induce a preterm delivery, thus saving the mother, and you do everything you can to try to save the child. You almost certainly fail, but you try.

'In current obstetrical practice rare complications can arise where therapeutic intervention is required at a stage in pregnancy when there will be little or no prospect for the survival of the baby, due to extreme immaturity. In these exceptional situations failure to intervene may result in the death of both the mother and baby. We consider that there is a fundamental difference between abortion carried out with the intention of taking the life of the baby, for example for social reasons, and the unavoidable death of the baby resulting from essential treatment to protect the life of the mother.'

In other words, for the hospital to have induced labour of the foetus with the intention of saving Savita, would, surely, have been in accord both with Irish law and normal Irish medical practice. It seems that such situations have nothing to do with the X Case, for all the well-meant cries that the failure of the Oireachtas to legislate for that is to blame here.

Bonnar elaborated on such situations as follows:

'We have never regarded these interventions as abortion. It would never cross an obstetrician’s mind that intervening in a case of pre-eclampsia, cancer of the cervix or ectopic pregnancy is abortion. They are not abortion as far as the professional is concerned, these are medical treatments that are essential to protect the life of the mother. So when we interfere in the best interests of protecting a mother, and not allowing her to succumb, and we are faced with a foetus that dies, we don’t regard that as something that we have, as it were, achieved by an abortion.

Abortion in the professional view to my mind is something entirely different. It is actually intervening, usually in a normal pregnancy, to get rid of the pregnancy, to get rid of the foetus. That is what we would consider the direct procurement of an abortion. In other words, it’s an unwanted baby and, therefore, you intervene to end its life. That has never been a part of the practice of Irish obstetrics and I hope it never will be.'

Despite having no shortage of friends who are medical practitioners of one sort or another, including embryologists, obstetricians, and midwives, I'm obviously not one myself so I'm not qualified to judge, but it seems to me that at least on the basis of the facts as reported, this was a straightforward and stomach-churning case of shocking -- possibly even criminal -- medical malpractice with a tragic outcome.

'In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.'

This is indeed the standard by which this affair should be judged. The problem here wasn't with the law.

The problem wasn't with religion either, for all that people are leaping to blame Galway's religious ethos, or the stupid and bizarre claims that 'this is a Catholic country'. Leaving aside how Ireland is not legally defined as a Catholic country, Catholicteaching allows for the normal Irish medical practice in this case, just as Irish law does.

The problem seems to have been solely with somebody -- for whatever reason -- failing to obey both the law and the medical profession's own code of conduct, and attributing their failure to Ireland being -- supposedly -- a Catholic country. If that's what's happened then people should be bloody furious about this.

But while anger's one thing, it makes no sense to talk of how this tragedy means we should change the law to make sure that this doesn't happen again. Law isn't magic: if doctors can disregard law and medical practice now, then they can do so in the future, regardless of what the law says.

At least based on the facts as reported, I don't see how new legislation would help here. There are clearly people who think Ireland's laws, which require that human life be respected and protected from conception to natural death, are barbaric and oppressive. I understand that, but regardless of what they think, it really seems that Ireland's laws weren't at fault here. I may turn out to be wrong, but as far as I can tell, this has nothing to do with the X Case.

There are investigations that need to run their course. There'll be a time for anger, and we should make sure it's the right kind of anger, and directed at the right target. In the meantime, I think it'd be best if Savita Halappanavar weren't treated as a political football.

Update: It's been pointed out to me that according to the reports, Savita was admitted to hospital with a miscarriage underway, her cervix being open from Sunday, but that antibiotics were only brought into play on Tuesday night, a full two days later; it's as though she spent two days there with an open wound. Again, I'm no doctor and would appreciate if someone could clarify this, but given that this was a case of death from infection, it seems to me to have been utterly egregious medical negligence from the start, and nothing whatsoever to do with the law, medical guidelines, or religious principles.

Hi, lots of useful facts here, good to hear from an intelligent gargoyle rather than the usual internet trolls! I did not know that level of detail about what the medical and church guidelines actually are. You have not addressed an important point though, which is that woman asked for an abortion in the majority of countries in Europe she would have been legally have received it. It is likely that it will be found that the doctor and hospital will not be found in the wrong here, but the fact remains anywhere (mostly) but Ireland she would still be alive today, well, perhaps, I am not a medical person either!

You seem to be making this an either/or argument. If not the law's fault, nor the church's fault, then it's an individual's fault? If clear legislation had been debated & passed, and if anti-abortion dogma (just as influential as actual text of religious teachings if not more so) wasn't so prevalent thanks to the likes of the Iona Institute & Youth Defence, maybe the individual would have been able to make a more informed decision. But I do agree that we need more information on the particulars of the case.

Speaking as a pharmacist (albeit in the UK), we need to know the law relating to medicine as well as our own Code of Ethics in order to practise within them. When faced with an ethical dilemma we should be able to justify our decision to our peers (ie other pharmacists). To this end we need to know our rights regarding consicence clauses and what they cover (and all healthcare practicioners need conscience clauses because all of us are constantly weighing up risks and benefits and make judgements as to what is best for the patient).

As Catholics we also need to know what the Church teaches. It is hard to talk about ending the life of an unborn child as "the unwanted side effect of a procedure" because that does rather put it on the same plane as a post-operative nausea and vomiting. However, if the life of the mother was in danger and the procedure in question would have saver her life, despite the fact that it resulted in the baby's death, it would have been morally justified.

I do not know the full details of this case, but if the doctor in question was a Catholic he is both a badly-informed Catholic and (especially if he is an obstetritian) a badly-informed doctor. I only hope that he was acting with the best intentions (which does not mean he should not answer before the law) and is not some nutjob trying to make some kind of point about the supposed evils of anti-abortion law.

Stephen - just because the lady requested an abortion is really not the point - in the sense that this would not decide whether or not it was best medical practice or the way to save her life here. Sounds like antibiotics rather than abortion were what was missing...

Here's how it sounds to me (the daughter of 2 nurses and working on a maternity unit at the moment).The woman has come in with threatened prem labour and in a great deal of pain. The threatened prem labour can be treated with either steroids to prevent it, or if she is fully dilated and the cervix can't be closed, she would need to be closely monitored and possible have an emergency evac - again as pointed out above, this is not an abortion.

I would suspect that because of the distress and pain, this poor woman felt that an abortion was an option to prevent her suffering further - even though she was actively miscarrying at the time. Her pain should have been treated and her treatment should have been a lot better.

In short, it does indeed look like medical malpractice to me and nothing whatsoever about abortion.

JL Pagano - as has been pointed out already, yes, it does appear to be the doctor here at fault because he/she HASN'T applied current legislation or treated the patient in line with best practice. Someone at the hospital has thrown around the word 'Catholic' and the patient has mentioned 'abortion' and the 2 have been thrown in together to create some sort of horrific scenario.

Hi Nozzy, perhaps antibiotics sooner was the solution that could have saved her life, seems like it. Theoretically, had she been in the UK, would anything have been different? Was "religious ideology" to blame or was it simply medical incompetence? I guess more details will come out, but we will still not get a perfect picture. The facts matter less to people than what they want to believe in these very emotional situations.

Abortion is not medicine - just the opposite. Abortion has nothing to do with this case. Ireland excels in obstetric and maternal medicine; Ireland has has the lowest maternal death rate in the world for about 30 years (contrasting with high rates for countries with high rates of abortion). This is the old dishonest MO of the pro-abortion lobby - to conflate abortion with medical treatment which in some very limited circumstances may result in the unintended death of the baby in utero. If we had an independent Media for the most part, nobody would be fooled by this absurd lie. As was once again explicitly confirmed by an International Symposium on Excellence in Maternal Healthcare recently held in Dublin, abortion is never medically indicated, never necessary to save a mother's life. Ireland's excellent statistics in this area make it a target for the pro-abortionists who cannot stand that they so eloquently exose the lie that abortion is medicine. Abortion just kills a baby, and kills many of the women who undergo it, leaving many others permanently mutilated (eg bowel perforation), infertile, psychologically traumatised, etc.

The commentary from the national Catholic Bioethics Center (in the USA) on the Arizona case that you link to is interesting and leads me to think the issue, from the point of view of Catholic ethics, is not as clear cut as you seem to indicate – although I suspect that you would be correct to suggest that in this case an evacuation of the uterus would ultimately have been licit.

It compares the case of removing a cancerous uterus (resulting in the death of the child) to that of removing the child from the uterus in response to hypertension when it is obvious the child is not viable ex utero. The first case is licit, the second is not.

This current case seems to lie between the two examples. And may indeed have shifted with time from being closer to the second to that of the first as the risk from infection grew. For example, your link suggests that evacuation of the uterus to remove infected material, and which would have removed the child simultaneously, would have been licit.

As your update notes, we might question whether the infection risk was properly understood by the medical team (I will not comment on the question as to whether it should have been or not). If this was not properly understood, then the risk to the mother`s life may have been tragically underestimated. Such an underestimation would naturally mean that from the medical team`s perspective there would have been greater doubt as to whether actions certain to remove the child from the uterus would be ethical, and indeed legal (given that they would not have thought it essential for saving the mother`s life).

This means that the detail of what happened is critical and so you are right to suggest that we need to let the investigation run its course.

We also need to remember just how good Irish maternal care is relative to virtually every other European country. It is practically the safest place to be for a pregnant woman. I hope this point is not overlooked in the inevitable discussion.

If your waters break and you don't go into labour you are carefully assessed for infection. Apparently this hospital was horribly cavalier with this womans health but I don't see how abortion was what would have saved her. Antibiotics were on a drip carefully monitored preferably since she was dilated. This whole case stinks of opportunism born of a womans needless death. Abortion can and does leave women open to infection and lacerations leading to complications (as I well know).

Fair points all. It is great to have a forum of intelligent informed opinion. It is too easy for these discussions to devolve into shouting matches.

I concede the point that removing a viable fetus is abortion, and this wasn't that. So when the woman asked for a termination and was denied it because the fetus had a heartbeat and "this is a Catholic country" she and the hospital were both wrong: she was not asking for an abortion and they were not denying her one!

There seems to have been other factors in play here though: why not just do the termination? (sorry if that is not the right word, I'm no doctor!) Why was it not considered the right treatment when medical guidelines and even church guidelines say so? The protesters here are arguing that those factors are bias caused by religious, racist and/or misogynistic attitudes. The truth may or may not come out in the investigation. Though it is fair to say most people have made up their minds all ready. I am still trying to keep an open mind: maybe this was just a tragedy. The definition of a tragedy being it was inevitable. But maybe it was not and lessons can be learned, in which case some good can come of it.

I also agree people have opportunistically used this woman's death to demand legislative change. Overdue political change usually gets a trigger like this. The reaction is disproportionate to the cause, and is more a reaction to an overall unsatisfactory state of affairs. Take the French Revolution or Arab Spring as examples. Although proportionately, these were bigger events, they were triggered by smaller events: there were only 9 prisoners in the Bastille and Mohamed Bouazizi was just one stall holder who committed a very public suicide after being mistreated by the police. The book Silent Spring is another example: http://en.wikipedia.org/wiki/Silent_Spring#Criticism

The main point I am making is you can"t dismiss the demand for change because the catalyst is not a perfect example of why change is demanded.

My educated guess from the facts provided is that following the D&C from the miscarriage there were retained products. This is usually the most likely cause of a maternal infection.If we don't learn anything from this, perhaps women can be a bit more clued up on definitions.

I flit between Ireland and England, skulking round churches, libraries, and museums, wetting my throat rather less often than I’d like, but perhaps more often than I should.
I suspect that the secret of life lies in laughter and humility, that only living things can go against the stream, that the riddles of God are more satisfying than the solutions of man, and that placed as sentinels of an unknown watch, we have a duty to whistle.
I think even more than I talk, and on good days I do so in that order.